01070044 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19978 RODRIGUES AVE 01070044
OWNER'S NAME: APPLICATION SyB DATE
BAKKER DAVID & ROBERTA 07/12/ 2001
PHONE: SANITARY NO. CONTROL NO.
❑s r
ECT'/ENGINEER: BUILDING PERMIT INFO
O
- BLDG '.ECT PLUMB MF-CH
LICENSED CONTRACTOR'S DECLARATION Job Description
hon 7000)th .1lotB ,i. n,CodenseRAISE EXISTING LIGHTS .ion7W0)of Division3ofthe Business anJ Prolessions Cole,anJ nhy licenses Yforce and enact.
slass S D pCComrectnr
ARCHITECT'S DECLARATION
understand my plans shall be used as public records
to
s Professional
OWNER-BUILDER DECLARATION
s =�1.1. 1 hereby affirm that 1 am exicnpt from the Contractor's Liccnxe Law for the I �j�
F a" following maxim(Section 7031.5.Rarities sort Professions Code Any city or county 0
f which mquims it permit m construct,alm,,improve,demolish,or repair any structurea,3 .prior to its issuance.also«claims the applicant for such pemut m flea signed statement - - - - -- a --
thathei5licensed purtdamrothe provisions of,hc Conaacmrs Limme Law(Chapter 9 ^^ .-Y3§9OF¢d}opr-gra p� Valuation
(connoicocing with Section 7000)of Division 3 of the�urines and Pmfc,oions Code)
I_;',p,as, 0 ., - gU�*�r: 11,.FwI
or that he is exempt therefrom and the basis for the allkged exemptlan.Any violation
of Section 7031.5 by any applicant for o permit subjects the,it,lieantlo a civil penally ,.,.,{,,.
,of not ream door five hundred dollm(S500L 304APNKOJGH ELECTRI AL' Occupancy Type
❑I,as owner of the proerty,ormyempmyeeswjtbwages astheirvote compensation, 501 FINAL ELECTRI AL ENERGY
wusine the work and the structure isnot intended areaeaw does
xmC(pply]Bast', 505 - FINAL EIWiG WRi;T GAILctions "
Business progeny
fm Who
Code The roves the is.ad License Low does now apply te an
r of property Who Wilds or improves at such and who does such work intended
or
owner ,
or through his own however
provided that mpM1 improvements is sol art not inrended or
offcrtd parxolc.IL how<ver,the building a Improvement Ix sols within one ychr of
coparomi for the owned sail.).will have the W,den O(proving that he did out WiIJ or
improve for purpose of sale.).
f the pmpcam exch i vela c trocf nh I" J emarroticarsh,
contract th p j t IScc.7BJJ,Bui tie. and Profts,imis
Code.)Th cammarchor, a
License Law does not apply man owner of property who bu Ids or improves thereoq
:- scr who contracts for such projects with a con mobi licemed pursuant to.dle
Cammcmr's License Law. is . . .,.
0 amcsitot derS c. - " B St'PC far this mamn +t a• ILII^H
a Ume 7-a pay(
OR PENSATION o "RAI N
I hereby affimh under penalty of perjury one of the following dtclamtions'.
p I have and will maintain a Carotica«of Consent to self-arse for Worker's
Compensation, as provided for by Section 3700 of the Labor Cale, for the
performance of the work for which this permit is issued.
❑I have and will'chairman Worker's'Compensation Insurance,as required by Section
37W of the Labor Cale,for the performance of the workfor which this pc5mi,is
issued.My Workers Compensation Insurance carie,and Policy number art: _ ,-
. car- 11• .. '. '. t " +.P,,i,sa •I '.tib'..,
CERTIFICATION OF EXEMPTION FROM WORKERS'' - -
s....rl �_.. ..-.COMPENSATION INSURANCE
" t -1pnotrscetiab need not be completed If the permit is for One hundred dollars
ISI W)or lCrS.) ,-
1 certify that in the pert rat nee f the Is for which his permits sued.
shall not employ any.person in any manner as to become subject m the Workers
Cnmidnsntion Law,of Coliform.,Date,'
Applicant
NOTICE TO APPLICANT. f.after making this Cenificae of Exemption,you should "
Z became subject to the Workers Compensation provisions of the Labor Cale,you most t
Q Q forthwith comply with such provisions.,,his permit shall W dmmed mvoked.
F:^ v a CONSTRUCTION LENDINGAGENCY" h
�. 1 hneby offon that thele is a construction lending agency for the performance
Of the work for which this permit is issued(Sec.3097.Co.C.1
..Lender's Name
.- •...._.
ns Q Lender',,Address - r
U Q 1 cenlfy drat 1 have read this appllca0nnrand salt that be above infmmshon Is
[a. F correct.I.,me an comply with all city and po ma,ordinances and ,are laws reform,
QU cobuildingconstruction. dh rchyaahorzempre.representatives fm.city n¢ Fon
the b t r, mY for inspection p Da.
E},I L IW 1"grt to r h do hxpe JAtthathe Ory fro Fenno against
V1 liabilities.judgments.costs ❑ pe hi may ch Y in any way accrue agpainstxaid
- U Z City in consequencef the granting f wh licroon.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
sill
S,aOs,UdcR�fn O�b
;
Issued by
: - - - -' - Dale
Ig - ApP icaevLontacmr Date Re-roofs
HAZARDOUSMATERIALS DISCLOSURE
Will the applicant or futureb IJgoompantnore orharriffle h" Ioson m-al , Type.of,Roof
y pe P ort Ch pt 0 12 nJ m I l hh and s fcly 1 x „I it
' tale Section❑ 353211.I ONo:. _ 'i ..fir. q� - i 1 .. , -' 'lt,v .',, S,
_.All.roofs shall be Inspected prior to any roofing material bei ng.installed.. .. ._..
Will the applicant or future bitldmg ocaapeal are equipment order,cos which) If a roof is installed without first obtaining an'inspectiori;'I agree to remove
omit hazardous air contaminants as defined by the Boy Arca Air Quality Munagemcnl
District! all new materials for inspection._Applicant understands and will comply with
over ON. -- - all non-poiht source regulations. I . - -
I have read the huzardeai materials reyuimments under Chapter 6.95 of The.
,California HnbM1&Safety CWe.Sccwion.c'_5505.25533 and 2553J.1 unJcmanJ thvt ,
ifihe Wam afire
which
W met prior
issuance
' -
dccupml of the requirements hereto¢which must be ren prior m i5suan<e of a CeniO<ate of
-. Occu,til -
-7, ret_ Signature of Applicant Date
"
r Or authorized agent Date All roof coverings to be Class "B" or better''
-' - S OFFICE